Case 1
An 86-year-old woman was diagnosed with RA at the age of 83 years. Due to the high disease activity of RA, she received tofacitinib (5 mg/day). This treatment did not significantly improve her disease activity score 28 (DAS28) score, which was initially 3.07 and improved to 2.93 after 3 months of drug therapy. The bone mineral density T-score of the left hip was -2.8, and she was subsequently diagnosed with osteoporosis. However, she received no treatment because she had not been prescribed a glucocorticoid. She complained of both gait and weight-bearing pain with varus deviation in the left ankle joint (Figure 1 A–C). At her initial visit, the radiographic findings in her left ankle joint were Larsen Grade IV in the talocrural joint and Larsen Grade III in the subtalar joint (Figure 2 A, B). Triamcinolone acetonide (15 mg) was injected into the left talocrural joint 5 months before surgery, but pain and swelling persisted. We decided to perform ankle arthrodesis to improve the patient’s functional outcome.
We used a transfibular approach during surgery. Both the talocrural and subtalar joints were exposed, and each joint surface was curetted. The finned intramedullary retrograde ankle nail (Intramedullary nail with fin, Teijin Nakashima Medical, Co. Ltd., Okayama, Japan) was inserted from the plantar side. Cancellous bone grafts were performed using bone harvested from the distal fibula (Figure 3 A, B).
After surgery, non-weight-bearing was maintained for 3 weeks. A patellar tendon-bearing orthosis was applied, and walking exercises were started 3 weeks after surgery. The orthosis was released, and free gait with full weight-bearing was started 3 months after the surgery.